Posts Tagged emergency department

A Blogger, Allegedly

So, it’s been awhile, eh?

It was Chuck Norris who found me.

To everyone who emailed and texted and Tweeted, thanks. Everything is hunky and dory. I’m not dead, ok? Let’s get that out of the way. Nor am I afflicted with a Chronic Debilitating Illness, unless you count members of my family. (That would be the topic of long separate blog post + extended psychotherapy.)

So what happened? Much to my surprise and amazement (and frank gratitude if truth be known) I got a new job about this time last year. A job with a very steep learning curve and a fairly cool boss with an alphabet soup of letters after her name and about as far away from Emergency nursing as you can imagine without leaving the hospital.

It is true, friends.

I have walked away from the front line.

I have drunk the mystical Kool-Aid.

I am Management.

But not real Management. I don’t actually manage anyone. I make up PowerPoints (ugh), give talks, and do research. I write policies. I have projects. I educate patients and staff.  I occasionally make recommendations to Important People many steps above my pay grade, When I do speak, the senior administration actually pays attention and sometimes will do this or that based on the words flowing out of my mouth. This is a bit of a revelation for a front-line nurse used to managers halfheartedly and reluctantly paying attention. OK, not really paying attention at all.

Nurse K once suggested to me that my ambitions for real management were probably misplaced. Having observed front-line managers from the other side up close for the past year, I have to agree. Being a front-line manager truly and deeply sucks. It’s far worse than being a charge nurse. (I say this as an embittered former old charge nurse, remember.) Awesome amounts of responsibility and no actual power. And navigating the snakepit which is hospital politics. And the risk of being walked off the property at will. Great job, right?

So first lesson: I think I dodged a bullet there. I really don’t want to be a manager.

Second lesson:  This is the first job where I use all of the skills I have acquired as a nurse in a meaningful and effective way.

I’m not just talking about clinical skills, or therapeutic communication skills which are surprisingly important in my current position; I’m also talking about evidence-based practice, critical thinking, leadership, understanding hospital processes, effecting change, teaching and developing clear presentations and a whole pile of other stuff — a whack of skills I acquired along the way in my ED practice.  The unfortunate fact is, the opportunities to develop and use all of these skill in front-line practice is limited. The fact I had to leave front-line practice to fully explore them is a telling, don’t you think?

Third lesson: Make the jump. I’m looking at all of you who think there must be more. Or better. Do something different. You won’t regret it.

Curiously enough a couple of days ago, someone named Darren Royds left this comment on one of my blog posts:

You need to get out and find a decent job. Have a life , live and reduce stress. I have quit nursing and was the best decision I ever made. You will end up as so many do.

Well exactly.  I haven’t quit nursing, though. But as much as I loved working in the ED, it was clearly time to move on. It was the best job decision I have ever made.

Have you guys ever made a career change to/from/within nursing? Was the outcome good/bad/indifferent?

 

 

P.S. So what about the blog?

That, dear friends, will be a topic for another blog post.

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When the Police Come Calling

The police are more-or-less a permanent fixture in every Emergency department. They bring in the drunks, the suicidal, the psychotic, the homeless and yes, the criminal, who have either sustained injuries as a result of their activities, or else have developed sudden (and convenient) cardiac symptoms upon their arrest. Most of us in Acme Regional’s ED will cooperate with the police to the point of expediting whatever they need us to do, which usually means filling out the Form 1 or medically clearing the patient. At the same time, most of are pretty clear that ED nurses and physicians are not an extension of the Police Service: police objectives and those of health care, to state the obvious,  are not the same.

It isn’t exactly mistrust. It’s more a wariness. There are ethical and legal issues involved. We cannot, for example, divulge patient information, so there is the constant dance of the police asking for information they know we won’t give them.  Come back with a subpoena, we tell them. They try anyway.

Then there is this: what do when the police bring in someone who, well, they’ve been beating on. It isn’t common, I should emphasize, but it isn’t so rare that it excites comment either. The police will say (nudge, nudge) the patient fell on the pavement while being arrested. Or banged his head while getting into the cruiser. Or the wall hit his face. Which may even be partly true. The patient usually says nothing at all.

So what do we do about it? Approximately nothing. We might document the injuries, in case there are  legal problems down the road. Or not. We are definitely not going to make any allegations about misuse of force. Who wants to travel that road, full of traps and pitfalls and paper by the mile plus, of course, the undying enmity of the local cops? I have seen a few pretty egregious cases, and we did exactly that — nothing. As well, I suppose many of us don’t want to second guess the police: I mean, who knows how things really go down, right? And we say, didn’t he deserve it anyway?

But how does this make anyone accountable? Including ourselves? And don’t we have a legal system in place to adjudicate innocence and guilt, and administer punishment?

It’s a moral swamp. And having thought about it long and hard, I’m not clear what, if anything, that can be done about it in practical terms. ED staff are not the guardians of the guardians. So we document. Poor excuse, I know.

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Epic Hitler Emergency Department Charge Nurse Rant

I never thought I’d use the words “Epic” and “Hitler” and “Emergency Department” and “Charge Nurse” and “Rant” as a blog title, but what the hell. I was bored one night and thought it would be fun to make a Hitler rant parody.

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Saved by Words for Friends

Ok, we’ve both been out of commission for a couple of weeks.  Our Miss Jean Hill, bright future of the nursing profession and co-blogger extraordinaire,  has a computer which has suffered last week the CPU equivalent of a massive cerebral bleed and maybe ethanol withdrawal too; the computer has since recovered, but Jean Hill’s nerves have been so shattered by the experience that it has left her tongue-tied, even catatonic. Which if you know Jean Hill, is a somewhat singular experience. At any rate, once she collects herself, she will be back. As for me, the schedule from hell and a lack of prewritten posts is my excuse. . . don’t you hate it when life gets in the way of what’s really important?

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The other day I was touring home from one of those interminable staff meetings about nothing at all, and I decided to stop in at an interesting-looking shop near Acme Regional. Since I live a little distance from my employment, my usual pattern is to race to the TorontoEmerg Lair and NurseCave on the nearest 400-series highway so I might more speedily savour the delights of Stately Doe Manor.

So I was innocently perusing the merchandise — mostly crap, alas — when someone tapped me on the shoulder. I looked around.

“Do you live around here?” a woman asked. She looked vaguely familiar.

“Uh, no.”

I need more vowels to spell crazy.

“You work at the hospital, don’t you.”

Goddamnit all to hell, I thought, except I inserted the f-bomb at least twice. Caught.

“Um, yes.”

And then she looked at me expectantly.She had the sort of blotchy complexion and body shape that suggested cholecystitis before 40. She seemed a little crazed, which made me a little, well, anxious. She clearly wanted me to comment on her mother’s/child’s/lover’s/nephew’s (or her) condition/prognosis/diagnosis/lab results/medications. Which, equally clearly, I couldn’t have done, even if I did remember her.

Then my phone buzzed.

“Excuse me,” I said. I stared intently at the phone and pretended the message was of such urgency and import as to leave me befuddled. I tapped the screen viciously.

She went away. I let out my breath.

There was no emergency. Of course it was nothing of the sort. It was my turn to play Words with Friends. Thank God for time-wasting aps.

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So I went to a second interview for a managerial position which in fact involves little actual management but is more administrative and actually fairly bomb-proof in an era of flat-lined hospital budgets. I actually really really want this position. I would feel fairly positive except the manager interviewing made what I have come to think of as the kiss of death statement: “It has been a real pleasure having the opportunity to get to know you.” Translation: Buh-bye, we will see you no more. Or am I parsing too much?

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Registered Nurses won’t make newspaper headlines, but your local sports pro will

Click to enbiggen

With Ontario’s Nursing Week approaching, May 7 – 13, posters for the Ontario Nurse’s Association (ONA, our union) campaign on supporting nurses the same way pro-athletes are have been put up around Acme Regional.

The conversation often arises among my colleagues about how a baseball player can make over 20 million dollars a year where 3 or 4 nurses’ lifetime salaries combined will never compare to that. I often feel bitter when I think of those in the business world who receive all sorts of financial and personal incentives for their work. People who go on all expense paid trips because they have sold the most insurance (selling you safety nets in case you fall, but you likely won’t, however you have to have it…) for example that year, meanwhile in that same year I may have resuscitated a child, held the hand of a dying man during his last breath and treated a father of 4 for a heart attack among caring for other incredible people. I received my same pay as always and more importantly, do not expect an incentive. I don’t feel bitter that I’m not getting a trip, I feel bitter that in this society, a pro-athlete or businessman is more supported than nurses. On the other side of the coin, it makes me wonder what sort of nursing culture would be bred if nurses were provided incentives for life saving measures or actions/treatment/education. And what treatments or care would be deemed “more important” than others, garnering a higher incentive? In the emergency department health teaching is imperative; to prevent illness and disease so one could argue that is as important as treating the patient having a stroke. If incentives in nursing existed would the wrong sort of people be attracted to the nursing profession? Some say it’s a calling, the art of the practice; only certain people can and will do the job and do it well have you. It would be worrisome to think that an individual would only want to save a life or teach parents about how to appropriately treat fevers if it meant they would get a financial bonus.

And yet, despite all of this, I still struggle with the fact that people who sell the most cars, buy the most stock in a company, etc… are seemingly more valued and appreciated then those that save lives, give people more time on earth and genuinely (most of us at least) care about humanity. I have a hard time finding the balance in it all. Emergency nursing is in the “business of life saving” is it not? With more and more facilities receiving incentives for improved and rapid physician to patient initial assessment times, where does appreciation for the nurses fall in to all of this?

(See also ONA’s website here and RNAO’s website for nursing week.)

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Nurses Grieve Too

An underexplored or ignored aspect of nursing professional life: how nurses working in a Labour and Delivery unit grieve over the loss of their patients, and how this grief affects care and support of survivors. What is really striking about the film is the culture of mutual support and respect among the nurses working in this unit — I hope it’s real and not just the product of the filmmaker’s eye, but the cynical side of me wants to think it’s idealized.

Though the film’s focus is in L & D, it makes me think of how nurses deal with loss in the Emergency department. The prevailing culture and mores of most EDs does not encourage touchy-feely moments, at least in not many of them. The expectation, frankly, is to suck it up and tough it out. The Emergency department is not for the weak of heart. Shrinking violets need not apply. Et cetera. But the question is whether we as nurses are able to provide good care to our patients without acknowledging and reflecting on how grief affects us. Or whether unacknowledged and unvalidated grief leads to higher burnout — and also some unintended psychological effects like PSTD.

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In Which TorontoEmerg is So Busted, or, Welcome, Jean Hill

A few weeks ago, I was talking with a colleague, whom I will call Jean Hill, and by-the-by the conversation fell to nurse bloggers. Several prominent ones were mentioned, like Crass-Pollination and Emergiblog and Nerdy Nurse.

“Oh,” said Jean Hill innocently. “I wish I could write like these guys.”

At which point your humble blogger’s eyes began to sparkle rather a cat’s contemplating a mouse. Come in my parlour, said the spider to the fly, I thought. You see, dear readers, I have been contemplating the addition of a co-blogger for some time. *

Nurse Jean Hill. (Dramatic reconstruction. Not intended to be an actual image.)

But how to lure the prey?

I told Jean Hill to meet me in the ambulance bay after shift. I told her portentously I had something I needed to ask her.

So later, in the ambulance bay, I told Jean Hill about this blog, my anonymity and whether or not she would like to come aboard the Good Ship Those Emergency Blues as a co-blogger.

She would, she said. She would be pleased. She had, she said, been reading the blog for a long time.

“So you knew about Those Emergency Blues?” I asked, secretly very pleased that someone from Acme Regional was reading it.

“Oh yes,” she replied. “And, you know, I knew it was you all the time.”

Oh crap. “Really?”

“Well, you sometimes talk like the blog, so I figured it out.”

By which, I suppose, she means I speak in a pedantic, self-important, pompous manner, but was too kind to say so. At any rate, I am very pleased Jean Hill has come to write here. I think she will be writing once or twice a week (hopefully more!) beginning in a few days on topics which interest her. Since this is her first time publicly writing a few small words of encouragement will be welcome.

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*For mostly selfish reasons, i.e. to ensure there is more content consistently posted, to free up time so I can write better for this blog, to work on some other writing projects, etc.

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More on When Labelling Patients Causes Patients to Die

In the comments WhiteCoat (of WhiteCoat’s Call Room fame) strenuously objects to my take on the Anna Brown case:

Wow.

Someone on my blog suggested that I check out this post after I just posted about this story yesterday.

To all of you who think “something more should have been done,” what should that “something” have been? She had multiple tests and exams performed for the same complaint – including sonograms which showed no blood clots the day before she died. She was having the same pain in her legs since she was hospitalized the week before. Gold standard test for DVTs is ultrasound. Do we repeat the ultrasound every day? Every hour? What other testing was “necessary”?

TorontoEmerg – think of all the patients you see with back pain requesting narcotic pain medications. Do you order serial MRIs on them to rule out the possibility of cauda equina? Or tumor? If so, what is the medical basis for the testing? If not, why? I’m assuming you don’t. When you miss the one patient who has a tumor and becomes paralyzed, you’ll be harangued because “obviously” the patient had something wrong and you neglected to address it. Yet once you tell the patients that they won’t be receiving any narcotic pain medications, many of the patients in severe pain stand up, curse at you, and storm out of the emergency department.

You say that Ms. Brown was “unable to walk.” The article showed that a nurse saw her standing the same day that she couldn’t walk. How many patients do you see who come to the emergency department and can’t get out of their car when they arrive? That’s a “red flag” that something is wrong. Do you order a million dollar workup on all of them? How many patients do you see who have had dozens of normal CT scans for their chronic abdominal pain? Is that proper medical care? I could go on and on, but you get the point.

The problem is that your post suffers from horrible hindsight bias. You knew the outcome and now you’re bashing the people who treated Ms. Brown because they didn’t have the ability to look into the future to see what would happen.

Yes, the outcome was horrible. Yes, there were miscues and miscommunication. I’m sure that Ms. Brown was “labeled” as someone trying to game the system. Society “labels” every aspect of our lives every day. President Obama is “liberal.” Ron Paul is “crazy.” Pit bulls are “dangerous.” Doctors are “rich.” Baby pandas are “cute.” Doing so doesn’t make us bad, it makes us human. Someone who was articulate and polite to the providers and to the police may have been treated differently. One of my readers said this was the “perfect storm” of events leading up to Ms. Brown’s death.

To say that Ms. Brown didn’t receive proper care or that her complaints were ignored is just wrong. I’m betting if you ordered all the testing you think Ms. Brown should have received on all of the patients who walked through the doors at your emergency department, *you’d* be the one being ridiculed.

I appreciate WhiteCoat taking the time to post such a lengthy reply. He fully explicates many of his points on his blog. I won’t editorialize much here, because I think his perspective is important to how we discuss cases like Anna Brown. I don’t share his point of view for a number of reasons, but I do agree with him that labelling people makes us human. The trouble starts, for me at least,  when we allow our interior — and often unrealized — biases to influence our care.

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Just Because I Don’t Remember You Doesn’t Mean I Didn’t Care

In the Emergency Department where I work, the number of patients we see pushes 200 some days. We assess and treat a lot of people, mostly for lumps and bumps, breaks and bruises, but also for major, cataclysmic, life-altering events — MIs, trauma, stroke, what-have-you.

I have a problem. The moment to the patient leaves the department I tend to forget them. Completely. If you are a run of the mill STEMI, I swear I will not remember you the next day. I may not remember you in an hour. A little while ago, my manager asked me about a case receiving some, um, legal attention. It was only after a good deal of prodding that I vaguely remembered — and this was a Code Blue! (Fortunately the legal formalities were about treatment received on previous visits, so I wasn’t directly involved. My charting was good, anyway.)

I do remember some cases which for one reason or another have stuck in my mind. (For example, like here. Or here. Or here, among others.) But mostly, nah. Maybe it’s because of the sheer volume. Maybe because my head will explode if I remembered the details on each and every patient. Maybe it’s just coping skills. Who knows. Anyone else have this problem?

Anyway, I was triaging the other day, and a patient told me how much she appreciated the care I gave her husband. (He was a Triple A, and survived.) I goggled at her for a second — we don’t frequently receive compliments in the ED — and said, “Yes, of course, I remember him.” She beamed. I made her happy. But I didn’t remember him at all. The patient’s husband was all in a day’s work for me — and a hugely important day in her life. We tend to forget what impact we have on patients and families. So a small lie for a good cause, I guess, a tiny bit of therapeutic communication.

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Some stupid to ponder, or how a local employer treats their nurses like idiots. Our local CCAC — the provincial agency which arranges for Home Care and related services — hath decreed that case managers are no longer permitted to use hospital-provided educational materials because 1) they haven’t been vetted by CCAC and 2) because the case managers haven’t been in-serviced on them.

Really.

CCAC evidently thinks their case managers — all RNs, by the way — are complete idiots in that they can’t tell patients using a hospital provided form when to come back the ED because (for example) their saline lock is infected. And CCAC believes that hospital put out bogus and misleading educational materials.

Sometimes you just have to shake your head. And mutter. Who comes up with these bonehead rules, anyway? Do managers lie awake at night thinking them up?

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On a personal note, thanks to all who emailed or tweeted or otherwise left messages of support regarding the family medical emergency a couple of weeks ago. All is well again, but I was a little frightened for a while. Your concern was really appreciated, and made me realize that I — we — have a great little community around this blog. Thanks!

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A Poem for Easter

My own, with at least Easterish themes of death and rebirth. Originally published on 7/10/10.

VSA

You came to us, no vital signs, no breath
Found dead, or nearly so, by the mall
You last saw cars, careening carts, a child.
Then falling, hard pavement, blood, a void empty
Of consciousness when help came, skin mottled.
(And paramedics glared and muttered Too late)
But still by breaking bones your heart caressing
Blood returned, with oxygen, drugs and life.
No life did we see, but a purple face,
(Though never we speak it, we thought Too Late,)
V fib, we worked the algorithm, shocked
Gave epi, shocked, and then surprising you,
You gasped, and meaning to die, you did not:
Eyes from a dark face stared incredulous.

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